Jennifer L. Gaudiani, MD, CEDS - iaedp · • A 23 year old started an intense workout program with...

Jennifer L. Gaudiani, MD, CEDSAssistant Medical Director, ACUTE

Associate Professor of Medicine, University of Colorado

Who are ACUTE patients?Who are ACUTE patients?pp

• 17‐65 years old (average 26)• 10% men• Average BMI on admission 12.5 kg/m2• Wide variety of pre admission function• Wide variety of pre‐admission function• Average length of stay around 2 weeks• From all over the country

Falling through the cracksFalling through the cracksg gg g

Too medically sick for me… ytoo mentally ill for you

Objectives: Motivation!Objectives: Motivation!jj

• Help empower you to translate to your p p y yclient:– The medical complications of severe caloricThe medical complications of severe caloric restriction and underweight

– The medical complications of severe purgingp p g g– The best practices of refeeding and detoxification from purging (advocate, p g g (educator)

– How to use knowledge of medical problems to promote recovery

Format: Discuss…Format: Discuss…

• Two cases• (Some) pathophysiologyp p y gy• Best practices to manage/fix• What we say to our patients• What we say to our patients• Literature/evidence

What is definitive stabilization?What is definitive stabilization?

• Use best medical evidence to provide safe• Use best medical evidence to provide safe, sensible, supported multidisciplinary care until patients meet our discharge criteria: p g– 2000‐3500 (oral) a day: sufficient to be gaining >1 kg lean weight weekly

– Labs normal or normalizing– Completed refeeding syndrome and no longer on electrolyte repletionelectrolyte repletion

– Bowels working, minimal edema (fluid overload)– Physically strong enough to transfer to mental health y y g gsetting

Medical complicationsMedical complicationspp

• In AN‐R– Organ dysfunction due to under‐weight and malnutrition

– High risk for refeeding syndrome

• In purging (AN or BN) – Type of purging used, frequency, and durationyp p g g , q y,– Detox can be complicated too

The good news:The good news:gg

Nearly all medical complications canNearly all medical complications can resolve with consistent nutrition and

full weight restorationfull weight restoration

Case: ANCase: AN‐‐RR

• A 23 year old started an intense workout program with her sorority sisters…couldn’t stop

• Over two years weight 34 kg 163 cm tall 60% IBW BMIOver two years, weight 34 kg, 163 cm tall, 60% IBW, BMI 12.5 kg/m2

• Insists on outpatient care the whole time• Has good energy and works full‐time, volunteers minimal

symptoms except early fullness when she eatsL b “fi ” j t i i h li t t d• Labs are fine …just some increase in her liver tests and a low white blood cell count

• Finally team and family insist on admission to a programy y p g

Case: ANCase: AN‐‐RR

• On further questioning:– Episodes of feeling sweaty and lightheadedS d ki f k b h– Stopped working out a few weeks ago because she was too fatigued

• She struggles with any sense she’s ill• She struggles with any sense she s ill– Discounts words of concern and over‐values statements of normalcy/praise

ANAN‐‐RR

• Refeeding syndrome• Gastroparesis

O t i• Osteoporosis• Low cell counts• HepatitisHepatitis• Hypoglycemia• Vital sign abnormalities• Cardiac abnormalities

Refeeding syndromeRefeeding syndromeg yg y

Potentially deadly syndrome that occurs when a starved person begins to take in p g

nutrition

Refeeding syndromeRefeeding syndrome

Ph h

g yg y

PhosphorousFood (carbohydrates)

consumedconsumedMetabolism of food pulls

phosphorous into ll d fcells, used for

energy building blocks

Low serum phosphorous


• Low phosphorous can be dangerous…or deadly• Full‐blown refeeding syndrome

i f il– Respiratory failure– Red and white blood cell dysfunction– Muscle breakdown– Seizures– Congestive heart failure– Cardiac arrestCardiac arrest

• Refeeding hypophosphatemia can be caught and corrected before complications


• Close monitoring prevents full‐blown syndromeClose monitoring prevents full blown syndrome– Start calories around 1400‐2000/day, low salt, <40% kcals from carbohydrates

• Important Australian contributions at the leading edge

– Intensive dietician input and supportAdvance by 400 kcal every 3 days checking– Advance by 400 kcal every 3 days, checking phosphorus levels daily in week 1, replete <3 mg/dL

– Encourage leg elevation, compression stockingsg g p g

Whitelaw M, Gilbertson H, Lam PY, Sawyer SM. Does aggressive refeeding in hospitalized adolescents with anorexia

Kohn MR. Madden S. Clarke SD. Refeeding in anreoxa nervosa: increased safety and efficiency through

nervosa result in increased hypophosphatemia? J Adolesc Health 2010;46:577‐582

understanding the pathophysiology of protein calorie malnutrition. Curr OpinPediatr 2011;23:390‐394

GastroparesisGastroparesispp

• Loss of normal stomach peristalsis (movement)– Causes early fullness, nausea, bloating, gassiness

– Nearly universal in severe underweight– Rarely is a nuclear med emptying study needed in this population

GastroparesisGastroparesispp

W S ll lWorsens- High fiber diets

- Smaller meals- Liquids/semi‐solidsL fib- Long time

underweightHigh fat diet

- Low fiber- With caution, metoclopramide 2 5- High fat diet

- Large mealsmetoclopramide 2.5 mg before meals, or erythromycin…limit y ytime use

Helps

What we tell our patients:What we tell our patients:pp

• Your weight has fallen so low that your whole body is slowing down to conserve energybody is slowing down to conserve energy.

• This should fully resolve once you have restored your weight.your weight.

PancytopeniaPancytopeniay py p

• Gelatinous Marrow• Gelatinous Marrow Transformation

R l t f ll d i– Replacement of cell‐producing marrow with an acellular “goo” due to starvationgoo due to starvation

– All cell lines may be affected– Source of inappropriate– Source of inappropriate workup

What we tell our patients: What we tell our patients: pp

• Your bone marrow is so starved, it’s stopped producing blood cells

ll f ll h h• It will fully recover with weight restoration• You don’t need a bone marrow biopsy or any � di i t l t thi i ’t�medicines to s mulate your marrow…this isn’t a marrow problem, it’s a starvation problem.

Vital signsVital signsgg

• Vital signs abnormalities highly prevalent• Adaptive, compensatory responses to malnutrition, “hibernation mode”– Bradycardia at rest (vagal tone)– Tachycardia with movement

• Deconditioning, not orthostasis• Helps distinguish between “athetic” and “starved”heart

Hypotension hypothermia– Hypotension, hypothermia


• Your heart rate is abnormally low and high because you are underweight and weak.

S dd di d th t f 30% f d th i– Sudden cardiac death accounts for 30% of deaths in anorexia, and we don’t exactly know what triggers the heart to stop.

• A human shouldn’t have hibernating vital signs. Your metabolism has slowed way down.– As soon as you you start to eat consistently, your furnace will turn back on.

OsteoporosisOsteoporosispp

• The one potentially irreversible complication– Onset of bone loss is rapid (2.5%/year) and severe

– By the end of the second decade, more than 90% of peak bone mass has been h d h l hachieved in healthy woman: in

adolescent‐onset AN this never occursHi hl l t– Highly prevalent

Mehler PS, Cleary BS, Gaudiani JL. Osteoporosis in anorexia nervosa. Eat Disord2011;19:194‐202


• Gold standard: weight restorationGold standard: weight restoration– Until resumption of menstrual cycle in women– 2010 Spanish study compared BMD improvement in p y p pAN patients restoring weight (20% mean increase in weight) with those who did not gain weight

A 2 i h d i d b d i 2• At 2 years, gainers had improved bone density 2 to 5%

• Non‐gainers had lost 1% to 4% bone densityNon gainers had lost 1% to 4% bone density

Olmos JM et al. Time course of bone loss in patients with anorexia nervosa. Int J Eat Disord 2010;43(6):537‐42


• EstrogenEstrogen– Virtually all RCTs conclude just say noconclude…just say no to estrogen

– Use obscures theUse obscures the benefits of natural menstrual cycle resumption (and precipitates monthly bl d l )blood loss)

Osteoporosis: ExerciseOsteoporosis: Exercisepp

• Doesn’t exercise help bone density?• Doesn t exercise help bone density?• While underweight: exercise worsens bone densitydensity

• Once restored: even intense exercise helps bone densitybone density

Waugh EJ et al. Effects of exercise on bone mass in young women with anorexia nervosa. Med Sci Sports Exerc. 2011 May;43(5):755‐63


• Serious exercise is a privilege of recovery.


• Men– Men typically have 1/3 the rate

f t ti hi d t b lof osteoporotic hip and vertebral fracture rates of women

– Men with AN had greater loss ofMen with AN had greater loss of bone than women even though men typically had shorter duration of their disorderduration of their disorder

– Men may fracture at higher bone density level than womeny

Mehler PS et al. High risk of osteoporosis in male patients with eating disorders. Int J Eat Disord2008;41(7):666‐72.

HepatitisHepatitispp

• Liver function tests (LFTs) are often elevated in severe AN• *Starvation mediated*:

• Autophagy on biopsy, recovers with p gy p y,refeeding.

• More common. • Often worsens for 1st week of refeeding.

• Refeeding mediated: S h i i i h l d f di• Steatohepatitis, recovers with slowed refeeding

HypoglycemiaHypoglycemiayp g yyp g y

P i ll d dl• Potentially deadly–Glucoses < 60 mg/dL are low– In underweight, result from depletion of glucose “building blocks” in liverg g

– Liver tests > 3 x normal predict hypoglycemiahypoglycemia

Case: PurgingCase: Purgingg gg g

• A 46 year old woman with a lifetime of AN‐BP presents again for admission. She has a BMI of 14 kg/m2.


• 50 stimulant laxatives daily• Purges by vomiting “up to 30 times daily”• GP has prescribed lots of oral potassium pills• In treatment may gain 5‐10 kg of water weight within days

• Often fails to have a BM for 2 weeks straight• Her cheeks typically swell painfully in treatment• She leaves AMA a lot


• Sodium 123, potassium 1.9, bicarb 42, BUN 31 and Cr is 1.1

d h h• Parotid hypertrophy

Purging (AN or BN)Purging (AN or BN)g g ( )g g ( )

• Properly managing volume depletion (dehydration)

d l l d• Avoiding volume overload• The potassium problem• Constipation and the perils of laxatives

PseudoPseudo‐‐Bartter SyndromeBartter Syndromeyy

S d• Secondary hyperaldosteronism

• Responsible for swelling• Responsible for swelling after purging cessation

• Causes urinary K loss• Causes urinary K loss• Resolves after 2 weeks of hydrated stateof hydrated state

Bahia A. Mascolo M. Gaudiani JL. Mehler PS. PseudoBartter syndrome in eating disorders. Int J Eat Disord 2012;45(1): 150‐3


• Key points to treat1. Stop purging2. Slowly give IV fluid (no faster than 50 ml/hr)3. (Or follow low sodium diet and 2‐3 liters

fluid a day), feet up4. Treat the hormone over‐production until

body downregulates


• To prevent edema from Pseudo‐Bartter pSyndrome

Perils of stimulant usePerils of stimulant use

• Constipation universal in severe underweightunderweight–Slowed GI transit

• High fiber worsens at low weights

ConstipationConstipationpp

• Manage expectantly– Set expectations for normal range of p gbowel function

–Polyethylene glycol no stimulantsPolyethylene glycol, no stimulants– Intestine works best at K of 4.5 or so

XX‐‐ray promiseray promisey py p

XX‐‐ray promiseray promisey py p

• Minimal stool?

• Lots of stool?• Lots of stool?

Cathartic Colon SyndromeCathartic Colon Syndromeyy

A.K.A “Why we don’t taper stimulant laxatives…we STOP them”laxatives…we STOP them

Questions?Questions?QQ

Jennifer L. Gaudiani, MD, CEDS - iaedp · • A 23 year old started an intense workout program with...

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